Comment on: Are intranasal corticosteroids all equally consistent in managing ocular symptoms of seasonal allergic rhinitis?

Dear Sir,

Allergic rhinitis (AR) affects an estimated 20% of the worldwide population. Allergic conjunctivitis, which often accompanies AR, has symptoms that include itching, tearing and redness. The nasal and ocular symptoms, when presented together, are referred to as allergic rhinoconjunctivitis. Oral antihistamines and intranasal corticosteroids (INSs) are prescribed for the treatment of allergic rhinoconjunctivitis; INSs have the potential effect of reducing ocular symptoms in patients with seasonal allergic conjunctivitis and to a lesser degree in patients with perennial allergic conjunctivitis, purportedly to a stronger degree than oral antihistamines, according to recent research.

A review in the August issue of CMRO1 examined whether INSs are equally consistent in managing the ocular symptoms of seasonal AR. The authors examined 35 randomized, placebo-controlled trials on seasonal AR and six INSs. They reported that fluticasone furoate was the only INS to demonstrate a consistent positive effect on ocular symptoms. This conclusion appears to contradict the common notion that all INSs have some effect on ocular allergy symptoms2.

Data in the published literature seem to support a class effect for INSs for the treatment of allergic rhinoconjuncitivitis3–5. This either may be a trend in the literature such as the analysis of traimacinolone5 or a specific primary or secondary outcome as seen in more recent studies of fluticasone and mometasone2,3,6. That type of treatment is thought to primary influence the eye through the naso-ocular reflex2–5,7. Studies on how specific INSs can improve AR and related eye symptoms have shown positive results – some more explicitly than others. For example, triamcinolone acetonide nasal spray, approved for AR, has been reported to show significant improvements in mean total eye symptoms scores compared with placebo, but obviously to a lesser degree than those studied for the specific impact on the total ocular symptom score (TOSS) as they were not designed to focus on the eye5. Studies of other INSs have shown similar trends.

There has not yet been a study that specifically compared INSs against each other for the treatment of AR ocular symptoms. The information reported here and in other studies supports a class effect from INSs for improving the symptoms of allergic rhinoconjunctivitis versus a unique effect to one type of nasal spray. Until a head-to-head study of INSs is performed, there is no real proof that one product has a stronger effect than the other.

Therefore, one should conclude that INSs have a class effect on reducing eye symptoms associated with allergic rhinoconjunctivitis although head to head studies might discern subtle differences between the INSs in the adverse event or beneficial effect profiles.

Transparency

Declaration of financial/other relationships

L.B. has disclosed that he holds stock in Ocusense and Advanced Plant Pharmaceuticals Inc. and has served on the advisory boards of several pharmaceutical companies. He has also received honoraria and research grants from several pharmaceutical companies.

References

• Keith PK, Scadding GK. Are intranasal corticosteroids all equally consistent in managing ocular symptoms of seasonal allergic rhinitis?. Curr Med Res Opin 2009;25:2021-41
   PubMed Web of Science ®Google Scholar
• Weber RW. Ocular impact of intranasal corticosteroid therapy: all that surprising?. Ann Allergy Asthma Immunol 2008;100:193
   Google Scholar
• Origlieri C, Bielory L. Intranasal corticosteroids: do they improve ocular allergy?. Curr Allergy Asthma Rep 2009;9:304-10
   Google Scholar
• Naclerio RM, Pinto J, deTineo M, et al. Elucidating the mechanism underlying the ocular symptoms associated with allergic rhinitis. Allergy Asthma Proc 2008;29:24-8
   PubMed Web of Science ®Google Scholar
• Bielory L, Georges G, Gross G. Treating the ocular symptoms of seasonal allergic rhinitis with triamcinolone acetonide aqueous nasal spray. Ann Allergy Asthma Immunol 2009;103:80-1
   Google Scholar
• Scadding GK, Keith PK. Fluticasone furoate nasal spray consistently and significantly improves both the nasal and ocular symptoms of seasonal allergic rhinitis: a review of the clinical data. Expert Opin Pharmacother 2008;9:2707-15
   PubMed Web of Science ®Google Scholar
• Gross G, Jacobs RL, Woodworth TH, et al. Comparative efficacy, safety, and effect on quality of life of triamcinolone acetonide and fluticasone propionate aqueous nasal sprays in patients with fall seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2002;89:56-62
   Google Scholar

Paul K. Keith and Glenis K. Scadding

McMaster University, Hamilton, Ontario, Canada; and Royal National Throat, Nose and Ear Hospital, London, UK

Authors' reply

Dear Sir,

We thank Dr Bielory for his thoughtful comment on our article on intranasal steroids (INS) and ocular symptom relief.

Since nasal inflammation appears to be responsible for at least some of the ocular symptoms of allergic rhinoconjunctivitis via neural reflex mechanisms and INS act as topical anti-inflammatories, it is to be expected that INS should reduce ocular symptoms as a class effect. Meta-analysis supports this INS effect, which is not significantly different from that of oral antihistamines1.

The fact that not all INS perform consistently in this respect almost certainly relates to their ability to reduce intranasal inflammation. This inconsistency makes it difficult to call this a class effect2. The molecule which is thought to be the most effective anti-inflammatory on the nasal mucosa is the only consistent performer in seasonal rhinitis trials thus far3.

It has been difficult to show superiority of one INS over another with respect to clinical effectiveness on nasal symptoms – although safety and acceptability are distinguishing features4. Ocular symptom reduction may be able to identify the best performers. A head-to-head trial would certainly be helpful to determine if this is an effect shown mainly by those at the top of their class.

Transparency

Declaration of funding

The original review article was sponsored by GlaxoSmithKline R&D, Ltd.

Declaration of financial/other relationships

P.K.K. has disclosed that he is the recipient of research funding and honoraria for lectures from GSK, Schering and Nycomed and a member of advisory boards for GSK, Schering and Nycomed. G.S. has disclosed that she is the recipient of research funds from GSK, lecture fees from GSK and Schering Plough and is a member of advisory boards for GSK and Schering Plough.

References

• Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998;317:1624-9
   PubMed Web of Science ®Google Scholar
• Keith PK, Toler WT, Lee LA. Ocular symptom efficacy and intranasal corticosteroids. Ann Allergy Asthma Immunol 2009 Dec;103:539;539-40
   Google Scholar
• Scadding GK, Keith PK. Fluticasone furoate nasal spray consistently and significantly improves both the nasal and ocular symptoms of seasonal allergic rhinitis: a review of the clinical data. Expert Opin Pharmacother 2008;9:2707-15
   PubMed Web of Science ®Google Scholar
• Herman H. Once-daily administration of intranasal corticosteroids for allergic rhinitis: a comparative review of efficacy, safety, patient preference, and cost. Am J Rhinol 2007;21:70-9
   PubMedGoogle Scholar